Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 65.00 - Long-term Care Insurance
Section 65.102 - Appendix A: Sample Definitions
Current through Register 1531, September 27, 2024
The following represent sample definitions of terms used in long-term care insurance policies. Any marketing or sales practices will be considered to be in compliance with the law if policies use substantially the same definitions and comply with all other laws related to the marketing of insurance policies.
Adult day care means dementia day care or social day care.
Adult day health means those nursing, educational, and rehabilitative services provided by an adult day health program.
Adult day health program means a program approved by the Massachusetts Division of Medical Assistance or by a program meeting the requirements of the state in which the adult day health services are provided.
Adult foster care means personal care and other related services provided ina family-like setting that are provided by programs approved bythe MassachusettsDivision of Medical Assistance or that meet the requirements of the state in which services are provided.
Assisted living facility means a facility that has been certified as an assisted living residence by the Massachusetts Executive Office of Elder Affairs or a facility meeting the requirements of the state in which services are provided.
Chore care means non-medical services that are provided in the insured's home and are designed to maintainthe insured's home so that it remains habitable, including at a minimum: vacuuming (including the moving of furniture), washing floors and walls, defrosting freezers, cleaning ovens, cleaning attics and basements to remove fire and health hazards, changing storm windows, performing heavy yardwork, shoveling snow, and making minor home repairs (such as replacing windows, door/window locks, handrails and safety rails, making minor repairs to stairs or floors and weatherizing the home).
Class means the underwriting and rating classifications originally used at the time that the policy was issued.
Community care benefits means those services provided to the insured in a home or community setting by a community-based service provider, including, but not limited to, personal care, home care and respite care.
Custodial care means non-medical services provided by a nursing home or a home health care agency.
Dementia day care means services provided by a dementia day care program operating in accordance with standards issued by the Executive Office of Elder Affairs, including a structured, secure environment for individuals with cognitive disabilities to maximize the individual's functional capacity, to reduce agitation, disruptive behavior, and the need for psychoactive medication, and to enhance cognitive functioning or a programmeeting the requirements of the state in which the dementia care is being provided.
Disability means the functional or cognitive inability to engage in the regular and customary activities of daily living without human assistance as measured by Activities of Daily Living (ADLs).
Elimination Period means the number of days of covered services that are to be paid solely by the insured before the insurance policy begins to pay benefits.
Guaranteed Renewable means the policy feature that guarantees the insured's right to continue the inforce insurance policy by the timely payment of premiums. A carrier cannot cancel, cannot decline to renew, and cannot make any unilateral change in any provision of a guaranteed renewable coverage without the agreement of the insured, but on a class basis, the carrier may revise premium rates for guaranteed renewable policies subject to the approval of the commissioner.
Home care means non-medical assistance with activities of daily living provided by a home care provider which are designed to maintain the insured's abilityto live independently and include, but are not limited to, shopping, planning menus, preparing meals, home delivered meals, laundry, and light house cleaning and maintenance, including vacuuming, dusting, dry mopping, dishwashing, cleaning the kitchen/bathroom and changing beds.
Home care provider means an entity that provides home care services and meets the provider requirements set forth by the Executive Office of Elder Affairs or a programmeetingthe requirements of the state in which the home care services are being provided.
Home Health Care means nursing, home health aide, rehabilitative therapy, and nutrition counseling services.
Home health care agency meansanagencycertifiedby the Massachusetts Department of Public Health or anagencyor programmeetingthe requirements of the state in which the home health care services are provided.
Hospice care means those palliative services provided by a hospice to a patient deemed to be terminally ill.
Hospice means an agency or program licensed by the Massachusetts Department ofPublic Healthor an agency or program meeting the requirements of the state in which hospice services are provided.
Hospita l means a facility licensed by the Massachusetts Department of Public Health or meeting the requirements of the state in which the facility is located.
Intermediate nursing care means routine nursing services with the periodic availability of skilled nursing and rehabilitative services that are provided by a nursing home, a home health care agency, or by an adult day health program.
Lifetime maximum benefit period means the maximum number of days of benefits, as chosen by the insured, which the carrier shall payfor covered benefits after the satisfaction of any elimination period or deductible.
Lifetime maximum dollar amount means the maximumdollar amount, as chosen by the insured, which the carrier shall pay for covered benefits after the satisfaction of any elimination period or deductible.
Medicaid means the program of medical assistance administered by the Massachusetts Division of MedicalAssistance under Title XIXofthe federal Social Security Act, 42 USCS §1396 et seq., and M.G.L. c 118E.
Medical necessity means:
(a) in accordance with accepted standards of medical practice for the diagnosis and treatment of a condition;
(b) delivered, when possible, in the least intensive setting required by the insured's condition; and
(c) not solely for the convenience of the insured or the insured's family or the insured's health care provider.
Medicare means the federal health insurance program under Title XVIII of the federal Social Security Act, 42 USCS §1395 et seq., as amended.
Mental or nervous condition means a condition as described in the standard nomenclature of the American Psychiatric Association.
Noncancelable means the policy feature that guarantees the insured's right to continue the in-force insurance policy at the same premium level by the timely payment of premiums. A carrier cannot cancel, cannot decline to renew, cannot make anyunilateralchange inany provision of coverage, and cannot revise premium rates for a noncancelable policy without the agreement of the insured.
Nurse means all nurses, including, but not limited to, registered nurses (R.N.), licensed practical nurses (L.P.N.), or licensed vocational nurses (L.V.N.) meeting the appropriate licensing or registration requirements of the state in which the nurse provides services.
Nursing home means a facility that is primarily engaged in providing nursing care and related services on an inpatient basis under a license issued by the Department of Public Health or the appropriate licensing agency of the state in which it is located.
Personal care means services provided by a personal care provider to assist in activities of daily living. Services provided by a personal care provider include, but are not limited to, assistance with bathing, bedpan routines, foot care, dressing, and care of dentures; shaving and grooming; assistance with eating; and assistance with ambulating and transfers.
Personal care provider means an entity that provides personal care services and meets the provider requirements set forth by the Executive Office of Elder Affairs or a programmeetingthe requirements of the state in which the personal care services are being provided.
Pre-existing condition means a medical condition for which an insured received diagnosis or treatment during the 24-month period prior to the effective date of coverage.
Respite care means services to temporarily relieve a caregiver of the daily stresses and demands of care for the insured. In addition to home care, personal care and home health care, respite care services may include but are not limited to short-termplacements inadult foster care, nursing facilities or rest homes.
Skilled nursing care means skilled nursing, rehabilitative and other related services provided by a nursing home or home health care agency.
Social day care means training, counseling, and social services as defined by standards issued by the Executive Office of Elder Affairs, including assistance with walking, grooming, and eating and planned recreational and social activities suited to the needs of the participants and designed to encourage physical and mental exercise and stimulate social interaction.
